A recent retrospective evaluation of pleural intervention data in the United Kingdom revealed that inadequate use of thoracic ultrasound contributed to both potential and actual harm from pleural procedures.
Previous national audits of pleural interventions, including chest drain insertions, have revealed deficiencies in care contributing to patient deaths and severe harm. Inadequate out-of-hours staffing by trained operators and related infrastructure issues have been identified as potential risk factors.
Consequently, a new review of patient safety incidents from the National Reporting and Learning System has been undertaken to assess whether the NHS is effectively mitigating these risks.
Concerns over procedural accuracy
Patient safety incidents (Levels 3, 4, and 5) involving harm from pleural interventions were obtained for the period between April 2018 and March 2022, excluding general anaesthetic procedures. Incidents specifically related to chest drain insertions and pleural effusion aspirations were analysed. Each event was reviewed for its location, timing, evidence of thoracic ultrasound use, equipment used, and the type of harm reported.
Out of 256 incidents, 21 were directly related to pleural interventions and were included for review. Among these, 17 incidents involved direct organ puncture – mostly of the liver – with various drain types used. This raises serious concerns about procedural accuracy.
Only four incidents explicitly reported the use of thoracic ultrasound, while its use was either unspecified or deemed inappropriate in the remainder. Most events (n= 19/21) occurred outside respiratory environments. Two of the 21 relevant incidents resulted in death.
Reflecting on how these findings should be interpreted, study authors pointed to a likely under-reporting of such incidents. ‘The true the amount of harm in the system is likely to be greater than identified and a more detailed investigation is needed,’ they said.
They also noted that the study focused on Level 3 incidents and above, and that re-expansion pulmonary oedema was excluded from the review, which should be included in future evaluations.
Prioritise national review of pleural interventions
Unequivocal in their recommendations for practice, the study researchers urged a nationwide review of local policies and procedures for pleural interventions. This should be prioritised ‘at a national level by specialty groups and societies, whose clinicians deliver pleural intervention’, they said.
Future, similar audits should be larger, more systematic and should clarify whether inadequate ultrasound use, or other factors contribute to these incidents, the authors concluded.
Commenting further on the implications of this study, lead author Dr Andrew Stanton said: ‘This study highlights the importance for teams in all clinical areas treating pleural effusions that ultrasound must be fully embedded in clinical protocols and used appropriately to provide safe intervention.’
His team concluded that stronger adherence to safety protocols and improved training will be key to reducing patient harm, and urge national organisations and NHS Trusts to take proactive steps to improve safety and standardisation in pleural care.
Reference
Stanton AE et al. Pleural procedural safety in the UK: is everyone’s house in order? Reflections from the BTS National Pleural Service Organisational Audit and a national review of patient safety incidents. BMJ Open Respir Res 2025;12:e002840.
